Healthcare Provider Details

I. General information

NPI: 1891850582
Provider Name (Legal Business Name): GLEATON HOME PROVIDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 WISTERIA DR
OXFORD GA
30054-4018
US

IV. Provider business mailing address

80 WISTERIA DR
OXFORD GA
30054-4018
US

V. Phone/Fax

Practice location:
  • Phone: 678-625-8897
  • Fax: 678-625-0619
Mailing address:
  • Phone: 678-625-8897
  • Fax: 678-625-0619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: NIKKI GLEATON
Title or Position: CEO
Credential:
Phone: 678-625-8897